The human gut microbiome is truly mind-boggling. We are teaming with microorganisms and their presence has been implicated not just in C. difficile colitis but in obesity, cardiovascular disease and a whole host of other diseases. The suggestion has even been made that our genetic code should be described as not only the DNA found within our cells, but as an amalgamation of that and the genes found in the microorganisms that surround and cover us – that the microorganisms are an intrinsic part of ‘us’.

You might have already seen a link on the homepage of this site to free e-learning for airway assistants in the ED. One of the challenges with FOAM resources is that it's not always clear what the background to them was or what process was undertaken in their creation. We've therefore published our method; the link to the article is here. Unfortunately it's not open access but you may be able to get it depending on your subscriptions.

When a patient bleeds they lose whole blood, but we also see a reduction in Hb concentration. The reason for this is apparently ‘transcapillary filling’ which always sounded to me like it could be bullshit (see earlier post). ​

The use of positive end expiratory pressure (PEEP) when ventilating patients in critical care is pretty universal, but it’s also true that we don’t entirely know how much to use and when. The rationale for PEEP is to prevent alveolar collapse (and possibly to take some role in recruiting areas already collapsed) and improve oxygenation. The costs of PEEP however are a rise in intrathoracic pressure (with the associated haemodynamic effects) and the risk of overdistension of lung units (leading to cytokine release etc.).

​The addition of Metronidazole to an antibiotic regimen is something generally done without much concern. We ‘trust’ Metronidazole to not cause resistance, and to do the job we ask of it. Why is that? I honestly can’t remember ever looking after a patient with an anaerobic infection resistant to Metronidazole.

​Recently we asked for a diabetes opinion for one of our patients. My colleague duly arrived and asked if we’d continued a medication I had no idea that the patient was on, or even which of the new groups of diabetes meds it belonged to. So I told him “I think so, yes” and snuck out of vision to check.

When a doctor diagnoses atrial fibrillation, 'the guideline' says that a CHA2DS2VASc and HAS-BLED score should be calculated, and depending on the outcome an anticoagulant given. We see a lot of AF in the critical care (not as much as in CICU but that’s a different game), but we don’t follow the guidance. Or at least I don’t, but why?

A recent opinion piece in BMJ careers argues that written reflection is ‘dead in the water’. I’d suggest you read it, but I personally disagree with most of it. I’ve tried to articulate my own counter-view in the five points below. What follows are my own beliefs, and I’d encourage you to leave a comment if (when?) you disagree.

​The EDEN trial is one of the go-to trials for feeding in the ICU. The paper can be found here, but essentially it recruited 1000 patients with respiratory failure, comparing different calorie targets for a period of 6 days. One group received 25% of requirements (the trophic feeding group), with the other aiming for full requirements (receiving 80% of goal).* The primary outcome was ventilator free days to day 28, with the study powered to detect a 2.25 day difference. 60 day mortality was a secondary outcome.